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THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, N.W. • Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the
Governing Board of the National Research Council, whose members are drawn
from the councils of the National Academy of Sciences, the National Academy
of Engineering, and the Institute of Medicine. The members of the committee
responsible for the report were chosen for their special competences and with
regard for appropriate balance.
This study was requested by the National Institute for Occupational Safety and
Health of the Centers for Disease Control and Prevention and was supported by
Contract No. 200-2005-10881 (Task Order #6), between the National Academy
of Sciences and the Centers for Disease Control and Prevention. Any opinions,
findings, or conclusions expressed in this publication are those of the author(s)
and do not necessarily reflect the view of the organizations or agencies that
provided support for this project.
International Standard Book Number-13: 978-0-309-11046-4
International Standard Book Number-10: 0-309-11046-7
Additional copies of this report are available from the National Academies
Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-
6242 or (202) 334-3313 (in the Washington metropolitan area); Internet,
http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page
at: www.iom.edu.
Copyright 2008 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America.
The serpent has been a symbol of long life, healing, and knowledge among
almost all cultures and religions since the beginning of recorded history. The
serpent adopted as a logotype by the Institute of Medicine is a relief carving
from ancient Greece, now held by the Staatliche Museen in Berlin.
Cover credits: Photographs of some of the various types of personal protective
equipment are reprinted with permission from Raymond Roberge, the National
Institute for Occupational Safety and Health, National Personal Protective Tech-
nology Laboratory; Jessica Young, Johns Hopkins University; iStockphoto.com,
Sean Warren; and Moldex Metric, Inc. (3200 Series with EZ-On® strap).
Suggested citation: Institute of Medicine. 2008. Preparing for an influenza pan-
demic: Personal protective equipment for healthcare workers. Washington, DC:
The National Academies Press.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of
distinguished scholars engaged in scientific and engineering research, dedicated to the
furtherance of science and technology and to their use for the general welfare. Upon the
authority of the charter granted to it by the Congress in 1863, the Academy has a mandate
that requires it to advise the federal government on scientific and technical matters. Dr.
Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the
National Academy of Sciences, as a parallel organization of outstanding engineers. It is
autonomous in its administration and in the selection of its members, sharing with the
National Academy of Sciences the responsibility for advising the federal government.
The National Academy of Engineering also sponsors engineering programs aimed at
meeting national needs, encourages education and research, and recognizes the superior
achievements of engineers. Dr. Charles M. Vest is president of the National Academy of
Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences
to secure the services of eminent members of appropriate professions in the examination
of policy matters pertaining to the health of the public. The Institute acts under the re-
sponsibility given to the National Academy of Sciences by its congressional charter to be
an adviser to the federal government and, upon its own initiative, to identify issues of
medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute
of Medicine.
The National Research Council was organized by the National Academy of Sciences in
1916 to associate the broad community of science and technology with the Academy’s
purposes of furthering knowledge and advising the federal government. Functioning in
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the principal operating agency of both the National Academy of Sciences and the Na-
tional Academy of Engineering in providing services to the government, the public, and
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Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest
are chair and vice chair, respectively, of the National Research Council.
www.national-academies.org

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COMMITTEE ON PERSONAL PROTECTIVE
EQUIPMENT FOR HEALTHCARE WORKERS
DURING AN INFLUENZA PANDEMIC
LEWIS R. GOLDFRANK (Chair), Bellevue Hospital Center and
New York University School of Medicine, New York
HOWARD J. COHEN, University of New Haven, West Haven,
Connecticut
JANINE JAGGER, University of Virginia, Charlottesville
SUNDARESAN JAYARAMAN, Georgia Institute of Technology,
Atlanta
TALMADGE E. KING, Jr., University of California, San Francisco
DONALD LOW, University of Toronto, Ontario, Canada
SHARON MARABLE, The Warren Alpert School of Medicine at
Brown University, Providence, Rhode Island
R. KENT OESTENSTAD, University of Alabama at Birmingham
School of Public Health
TRISH M. PERL, Johns Hopkins University School of Medicine,
Baltimore, Maryland
DAVID PREZANT, Albert Einstein College of Medicine, Brooklyn,
New York
M. E. BONNIE ROGERS, University of North Carolina School of
Public Health, Chapel Hill
Staff
CATHARYN T. LIVERMAN, Project Director
FRANKLIN BRANCH, Research Associate (since April 2007)
NORA HENNESSY, Research Associate (until March 2007)
JUDITH ESTEP, Program Associate
v

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Independent Report Reviewers
This report has been reviewed in draft form by individuals chosen for
their diverse perspectives and technical expertise, in accordance with
procedures approved by the National Research Council’s Report Review
Committee. The purpose of this independent review is to provide candid
and critical comments that will assist the institution in making its pub-
lished report as sound as possible and to ensure that the report meets in-
stitutional standards for objectivity, evidence, and responsiveness to the
study charge. The review comments and draft manuscript remain confi-
dential to protect the integrity of the deliberative process. We wish to
thank the following individuals for their review of this report:
Lisa Brosseau, School of Public Health, University of Minnesota
Bruce Burlington, Wyeth Pharmaceuticals
Patricia Butterfield, Intercollegiate College of Nursing, Washington
State University
Barbara DeBaun, Patient Safety & Infection Control, California Pacific
Medical Center
David DeJoy, College of Public Health, University of Georgia
Zane Frund, Mine Safety Appliances Company
Sergey Grinshpun, Department of Environmental Health, University of
Cincinnati
Nancy E. Kass, Berman Institute of Bioethics, Johns Hopkins
Bloomberg School of Public Health
Leonard A. Mermel, Division of Infectious Diseases, Rhode Island
Hospital
James Platner, Center to Protect Workers’ Rights, Silver Spring,
Maryland
vii

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viii INDEPENDENT REPORT REVIEWERS
Rosemary Sokas, Environmental and Occupational Health Sciences,
School of Public Health, University of Illinois
Robert D. Sparks, TASER Foundation, Scottsdale, Arizona
Although the reviewers listed above have provided many construc-
tive comments and suggestions, they were not asked to endorse the con-
clusions and recommendations nor did they see the final draft of the
report before its release. The review of this report was overseen by
Linda Hawes Clever, California Pacific Medical Center, University of
California. Appointed by the National Research Council and the Institute
of Medicine, she was responsible for making certain that an independent
examination of this report was carried out in accordance with institu-
tional procedures and that all review comments were carefully consid-
ered. Responsibility for the final content of this report rests entirely with
the authoring committee and the institution.

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Preface
The Institute of Medicine (IOM) study that resulted in this report had
its beginnings in the discussions of an IOM standing committee estab-
lished to examine the role of the National Personal Protective Technol-
ogy Laboratory (NPPTL) of the National Institute for Occupational
Safety and Health in preventing work-related injury and illness. Our
committee felt that there was no better strategy to address the NPPTL
mission than through investigating how to protect healthcare workers in
the event of an influenza pandemic.
Influenza is a viral syndrome associated with acute manifestations of
disease in the upper and lower respiratory tract. Those of us in health
care know the cycle of events: discussion of the annual epidemic, plan-
ning the design of the specific year’s vaccine, plans for hospital staff
immunization, and the probability of significant staff illness and the
deaths of 20,000 to 40,000 people across the country with billions of dol-
lars in loss of life and productivity even in the best of years. The discus-
sion then shifts to the possibility of pandemic influenza, which has
occurred every 10 to 50 years since the 1890s. It is these thoughts, the
global implications of a new disease as seen in severe acute respiratory
syndrome and the recognition of the worldwide potential for catastrophe
if a pandemic of influenza were to occur that led us to focus on the
NPPTL mission as it relates to pandemic influenza.
This problem seemed ideally suited for investigation by an interdis-
ciplinary committee of the IOM utilizing experts in infectious diseases,
infection control, internal medicine, emergency response and prepared-
ness, emergency medicine, public health, materials engineering, and oc-
cupational safety and health. The committee proved to be well balanced,
ix

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x PREFACE
thoughtful, and provocative and worked diligently to examine the scien-
tific literature and discuss the wide range of relevant issues.
Throughout this study, the committee was disappointed to learn of
the remarkable scientific and public policy limitations that hinder pro-
gress in the area of preparedness for a pandemic: limitations in under-
standing the behavior of the influenza virus, limitations in the extent of
testing (pre- and post-market) of personal protective equipment (PPE)
products to meet real-world working conditions, and limitations in edu-
cation, training, and institutional support for improving PPE compliance
by healthcare workers.
Many critical questions about influenza transmission must be an-
swered to enable progress in the technical design of individual PPE com-
ponents (such as respirators and appropriate PPE ensembles including
gowns, eye protection, and gloves). The standards for PPE approval and
ongoing evaluation at the Food and Drug Administration do not adhere
to the same high standards as for new drugs or vaccines. It is our belief
that healthcare workers will feel secure only when the PPE that they are
asked to wear is as safe and effective as the vaccines and medications
they are asked to take.
The concept of the culture of safety must assure each worker that in-
stitutional policies are devoted to protecting all patients and healthcare
workers to the greatest extent possible. Success can only be achieved by
individual discipline and integrated team training of all participants (in-
cluding nurse aides, nurses, respiratory therapists, clerks, housekeepers,
physicians, and others) in a natural environment and/or a simulated envi-
ronment that reinforces understanding of errors, risks, and ultimately
competence.
Our committee suggests many local, national, and international ap-
proaches that could, in fairly short order (possibly 1 to 3 years), fill the
numerous gaps in preparing for pandemic influenza—healthcare team
development, coordination of federal efforts, and a renewed commitment
to the study of influenza transmission and prevention through an interna-
tional research network. Expeditious efforts are needed to advance this
action plan so that healthcare workers will feel secure enough to leave
their homes, come to work, work effectively, and return to their loved
ones during an influenza pandemic.
Lewis Goldfrank, Chair
Committee on Personal Protective Equipment
for Healthcare Workers During an Influenza Pandemic

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Acknowledgments
The committee wishes to acknowledge the valuable contributions
that were made to this study by many individuals who shared their
expertise with us. The committee is very appreciative of the presentation
by Michael Bell at its first meeting in December 2006. The committee
greatly benefited from the opportunity for discussion with the researchers
and healthcare professionals who presented informative talks at the
committee’s scientific workshop in February 2007 (Appendix A). We
also thank those individuals who provided testimony during the public
comment session (Appendix A). The National Personal Protective
Technology Laboratory (NPPTL) sponsored this study; and the
committee greatly appreciates the assistance and the support that it
received from Les Boord, Maryann D’Alessandro, and Roland Berry
Ann among many others at NPPTL.
The committee wishes to thank the many individuals who discussed
specific issues with committee members. The committee particularly
wants to thank Robert Couch, Fred Hayden, Edwin Kilbourne, Marc
Lipsitch, Anice Lowen, Arnold Monto, Samira Murbaeka, John Oxford,
and John Treanor. We also thank Joseph Schwerha for the technical
review he provided. We appreciate all the input received from interested
individuals and organizations.
xi